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Practice Nurse

Assessing Chest Pain

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This resource tests your knowledge of signs, symptoms and conditions associated with Chest Pain.


Nurses, in both primary and secondary care, are often called upon to provide first point of contact care for people with a range of signs, symptoms and conditions. In the case of chest pain, the importance of thorough history taking, careful assessment, including examination, and the use of objective tests to ascertain whether the pain is likely to be cardiac or non- cardiac in origin, cannot be underestimated. Thorough assessment will allow the safest and most appropriate course of action to be taken.


After working through the article on the preceding pages, you should be able to:


Discuss the importance of effective history taking when assessing chest pain

Describe the key features of chest pain which affect the likely diagnosis

Broadly describe how to differentiate between cardiac and non-cardiac chest pain

Apply evidence based guidelines when deciding how to manage chest pain at the initial presentation.

Nurses, in both primary and secondary care, are often called upon to provide first point of contact care for people with a range of signs, symptoms and conditions. In the case of chest pain, the importance of thorough history taking, careful assessment, including examination, and the use of objective tests to ascertain whether the pain is likely to be cardiac or non- cardiac in origin, cannot be underestimated. Thorough assessment will allow the safest and most appropriate course of action to be taken.



Cardiovascular disease

Liam, a 45-year old factory worker, presents at the surgery. He is feeling generally unwell and is complaining of left sided chest pain. He smokes 30 cigarettes a day and has a cough that is now productive of greenish-yellow sputum.

He has had the chest pain since last night. It is stabbing in nature and worse on coughing or breathing deeply. He has a fever and an elevated pulse and respiratory rate.

Based on this immediate history, what is the most likely diagnosis?

The distribution and nature of the pain makes angina unlikely.

Although pulmonary embolism and pneumothorax can also cause stabbing chest
pain, worse on coughing, the fact that Liam has an elevated temperature and a
productive cough makes pneumonia, and associated pleuritic pain, the most likely
diagnosis.

Question 1

Alice, aged 37, is a busy waitress. She presents complaining of episodes of retrosternal chest pain for the last three months. Most often these episodes are worse at night and she thinks they are aggravated by eating late at night, or drinking alcohol. She has also developed an irritating dry cough that is worse on lying down and first thing in the morning when she gets up, but does not wake her at night.
She has no significant family or previous medical history and does not smoke.
What is the most likely cause of her symptoms?


The most likely cause of Alice's symptoms is GORD. GORD is also a common cause of
chronic cough, which may or may not be accompanied by typical symptoms of reflux
- i.e. retrosternal pain and reflux of acid into the mouth - and can be confused with
late onset asthma.

Peptic ulceration is also a possible diagnosis, although the presence of cough makes
GORD most likely.


Question 2

Mrs Jones is a 45-year old teacher who is brought into the surgery by a work colleague,
having refused to allow the school to call an ambulance.

She is very distressed and has chest pain. This does not radiate anywhere and she describes
it as 'tight and all around my rib cage'. The pain came on after an altercation with a
particularly difficult 15-year old pupil who was verbally abusive and threatened physical
violence.

She has a tachycardia, is clammy and nauseous and has a rapid, shallow, respiratory rate.
Her blood pressure is also slightly elevated.

She has no history of hypertension or other significant medical history, has never smoked,
is not overweight and is otherwise fit and active. (She walks the dog twice a day and goes to
the gym twice a week). She has no family history of cardiovascular disease.

While you are calmly assessing her you give her reassurance and she begins to relax. Her
respiratory rate slows and the pain eases. Her blood pressure drops to 126/74.

What is the most likely cause of her symptoms?


Mrs. Jones's pain is not typical of myocardial infarction or angina. Pulmonary
embolism is most likely to cause a localised, pleuritic pain.

Her presenting symptoms, plus the fact that she has just had an unpleasant and
frightening experience, has no significant risk factors for cardiovascular disease
and improves with calm reassurance, makes anxiety the most likely cause for her
presentation.


Question 3

Ray is 67 years old. He has a long history of hypertension (poorly controlled) and has tried,
in vain, to stop smoking. He is also overweight and sedentary.

Ray's wife brings him into the triage clinic at the surgery. He has severe central chest pain
that came on an hour ago, at rest, and is radiating into his back and jaw. He is clammy and
has vomited. His blood pressure is low, he has a tachycardia and his pulse is 'thready' and
irregular.

You suspect an acute coronary syndrome and have arranged emergency transfer, by
ambulance, to hospital.

What would be your next steps while waiting for the ambulance?


A 12-lead ECG is appropriate, but this should not delay his transfer to hospital and
the results of the ECG should not influence the decision to admit him. ECG changes
typical of acute coronary syndrome may take time to develop.

Oxygen should be used with caution. Pulse oximetry should be available in all health
care settings. If the saturation is less than 94% oxygen should be given to achieve
an oxygen saturation of 94-98%. Patients with COPD, who are at risk of hypercapnic
respiratory failure, should be given oxygen to achieve a saturation of 88-92%.
Nitrate should not be given to patients who are hypotensive.


Question 4

Graham is a 52-year old who has recently moved into the area. He and his wife are doing
up an old house in the area. He presents with left sided chest pain that radiates into his left
arm. The pain started suddenly as he was lifting a ladder into place, and is aggravated by
changing position and pressure over the left side of his chest.

His vital signs are normal and he is not obviously distressed. He has no significant previous
medical history, does not smoke and is not overweight. He has a family history of diabetes
and his aunt had cardiovascular disease.

You decide that the most likely cause of Graham's chest pain is musculoskeletal.
What would you do next?


Simple musculoskeletal chest pain will usually resolve without further treatment and
does not require further investigation.

Because Graham has a family history of diabetes a blood sugar may be useful, as a
baseline and to rule out type 2 diabetes. His family history of cardiovascular disease
is in a secondary relative so may not be significant.


Assessing Chest Pain

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